Stylet angulation for routine endotracheal intubation with McGrath videolaryngoscope

Airway Management of Patients with Suspected or Confirmed COVID-19: Survey Results from Physicians from 19 Countries in Latin America

Airway management during the COVID-19 pandemic has been one of the most challenging aspects of care that anesthesiologists and intensivists face. This study was conducted to evaluate the management of tracheal intubation in patients with suspected or confirmed COVID-19 infection. This is a cross-sectional and international multicenter study based on a 37-item questionnaire. The survey was available to physicians who had performed intubations and tracheostomies in patients with suspected or confirmed COVID-19 and had provided informed consent to participate. The primary outcome is the preference to use a specific device for tracheal intubation. Secondary outcomes are clinical practice variables, use of video laryngoscopes, difficult airway management, and safety features to prevent cross-infection. This study included 2411 physicians who performed an average of 11.90 and 20.67 tracheal intubations in patients diagnosed or suspected of having COVID-19 disease, respectively. Physicians were mainly from the specialties of Anesthesiology (61.2%) and Intensive Care (7.4%). COVID-19 infection diagnosed by positive PCR or serology in physicians participating in intubation in this study was 15.1%. Respondents considered preoxygenation for more than three minutes very useful (75.7%). The preferred device for tracheal intubation was the video laryngoscope (64.8%). However, the direct laryngoscope (57.9%) was the most commonly used, followed by the video laryngoscope (37.5%). The preferred device to facilitate intubation was the Eschmann guide (34.2%). Percutaneous tracheostomy was the preferred technique (39.5%) over the open tracheostomy (22%). The predicted or unpredicted difficult airway management in these patients was preferably performed with a video laryngoscope (61.7% or 63.7, respectively). Intubation was mostly performed by two or more expert airway physicians (61.6%). The use of personal protective equipment increased the practitioners' discomfort during intubation maneuvers. The video laryngoscope is the preferred device for intubating patients with COVID-19, combined with the Eschmann guide, flexible stylet within the endotracheal tube, or Frova guide to facilitate intubation. The sub-analysis of the two groups of physicians by the level of intubation experience showed a higher use of the video laryngoscope (63.4%) in the experts group and no significant differences between the two groups in terms of cross-infection rates in physicians, in their preference for the use of the video laryngoscope or in the number of intubations performed in confirmed or suspected COVID-19 patients.

Airway management of COVID-19 patients: A survey on the experience of 1125 physicians in Spain

BACKGROUND

We explored the experience of clinicians from the Spanish Society of Anesthesiology (SEDAR) in airway management of COVID-19 patients.

METHODS

An software-based survey including a 32-item questionnaire was conducted from April 18 to May 17, 2020. Participants who have been involved in tracheal intubations in patients with suspected or confirmed COVID-19 infection were included anonymously after obtaining their informed consent. The primary outcome was the preferred airway device for tracheal intubation. Secondary outcomes included the variations in clinical practice including the preferred video laryngoscope, plans for difficult airway management, and personal protective equipment.

RESULTS

1125 physicians completed the questionnaire with a response rate of 40,9%. Most participants worked in public hospitals and were anesthesiologists. The preferred device for intubation was the video laryngoscope (5.1/6), with the type of device in decreasing order as follows: Glidescope, C-MAC, Airtraq, McGrath and King Vision. The most frequently used device for intubation was the video laryngoscope (70,5%), using them in descending order as follow: the Airtraq, C-MAC, Glidescope, McGrath and King Vision. Discomfort of intubating wearing personal protective equipment and the frequency of breaching a security step was statistically significant, increasing the risk of cross infection between patients and healthcare workers. The opinion of senior doctors differed from younger physicians in the type of video-laryngoscope used, the number of experts involved in tracheal intubation and the reason that caused more stress during the airway management.

CONCLUSIONS

Most physicians preferred using a video-laryngoscope with remote monitor and disposable Macintosh blade, using the Frova guide.

Comparison of the intubation success rate between the intubating catheter and videolaryngoscope in difficult airways: a prospective randomized trial

BACKGROUND

Several devices and algorithms have already been examined and compared for difficult airway management. However, there is no existing study comparing the success of the Intubating Catheter (IC) and the Videolaryngoscope (VL) in patients who are difficult to intubate. We aimed to compare Frova IC and McGrath VL in terms of intubation success rates in patients with difficult intubation.

METHODS

This prospective, randomized study was performed in an university hospital. Patients who underwent an operation under general anesthesia and whom airway management process was deemed difficult were included in this study. Patients were randomly divided into two groups by envelopes containing a number: the intubating catheter group (Group IC), intubated using the Frova IC, and the videolaryngoscope group (Group VL), intubated using the McGrath VL. Study data were collected by a technician who was blind to the study groups and the type of device used in the intubation procedure.

RESULTS

A total of 49 patients with difficult airway were included in the study, including 25 patients in the Frova IC Group and 24 patients in the McGrath VL Group. The rate of successful intubation was determined to be 88% in Group IC and 66% in Group VL (p = 0.074). The mean duration of intubation attempt in Group VL was 44.62 seconds, whereas in Group IC, it was 51.12 seconds (p = 0.593). Group VL was found to have a significantly lower Cormack-Lehane grade compared to Group IC (p < 0.001).

CONCLUSION

Frova IC is a candidate to be an indispensable instrument in terms of cost-effectiveness in clinics such as anesthesia and emergency medicine, where difficult intubation cases are frequently encountered. However, the combination of Frova IC and McGrath VL seems to be more successful in difficult intubation situations, so future studies should focus on using these two devices together.

Comparison of McGrath Videolaryngoscope and Macintosh Laryngoscope in Children with Torticollis: Randomized Controlled Trial

We investigated the efficacy of the McGrath videolaryngoscope compared with the Macintosh laryngoscope in children with torticollis. Thirty children aged 1–10 years who underwent surgical release of torticollis were randomly assigned into the McGrath and Macintosh groups. Orotracheal intubation was performed by a skilled anesthesiologist. The primary outcome was the intubation time. The Cormack–Lehane grade, lifting force, intubation difficulty scale (IDS), difficulty level, and intubation failure rate were also assessed. The intubation time was significantly longer in the McGrath group than in the Macintosh group (31.4 ± 6.7 s vs. 26.1 ± 5.4 s, p = 0.025). Additionally, the Cormack–Lehane grades were comparable between the groups (p = 0.101). The lifting force and IDS were significantly lower in the McGrath group than in the Macintosh group (p < 0.001 and p = 0.022, respectively). No significant differences were observed with respect to endotracheal intubation difficulty and intubation success rate. Intubation-related complications were also not observed. In conclusion, compared with the Macintosh laryngoscope, the McGrath videolaryngoscope extended the intubation time and did not improve glottic visualization in children with torticollis, despite having a lesser lifting force, lower intubation difficulty scale, and similar success rate.

Efficacy of stylet angulation at the holding position during tracheal intubation with a videolaryngoscope: a randomized controlled trial

The aim of this randomized controlled trial was to determine the efficacy of stylet angulation at the holding position during tracheal intubation with a McGRATH MAC videolaryngoscope. Patients were randomized to a group for intubation without stylet angulation at the holding position (non-angulation group) and to a group for intubation with stylet angulation at the holding position (angulation group). The primary outcome was the time for placement of the tracheal tube. Sixty patients were analyzed. The mean (standard deviation) times for tube placement were 21.3 (5.6) s in the non-angulation group and 16.9 (3.8) s in the angulation group (P < 0.001). The scores of operator's perception of difficulty in tube delivery, number of attempts for tube delivery, and degrees of extension, abduction, internal rotation of the right upper arm and extension of the right wrist during tube placement in the angulation group were significantly smaller than those in the non-angulation group (P < 0.001, P = 0.002, P < 0.001, P < 0.001, P < 0.001, P < 0.001, respectively). Our results suggest that stylet angulation at the holding position improves maneuverability of the tracheal tube and enables easy, smooth, and swift tube placement during tracheal intubation with a McGRATH MAC videolaryngoscope.

The Impact of Personal Protection Equipment on Intubation Times

INTRODUCTION

Hazardous material (HAZMAT) protocols require health care providers to wear personal protective equipment (PPE) when caring for contaminated patients. Multiple levels of PPE exist (level D - level A), providing progressively more protection. Emergent endotracheal intubation (ETI) of victims can become complicated by the cumbersome nature of PPE.

STUDY OBJECTIVE

The null hypothesis was tested that there would be no difference in time to successful ETI between providers in different types of PPE.

METHODS

This randomized controlled trial assessed time to ETI with differing levels of PPE. Participants included 18 senior US Emergency Medicine (EM) residents and attendings, and nine US senior Anesthesiology residents. Each individual performed ETI on a mannequin (Laerdal SimMan Essential; Stavanger, Sweden) wearing the following levels of PPE: universal precautions (UP) controls (nitrile gloves and facemask with shield); partial level C (PC; rubber gloves and a passive air-purifying respirator [APR]); and complete level C (CC; passive APR with an anti-chemical suit). Primary outcome measures were the time in seconds (s) to successful intubation: Time 1 (T1) = inflation of the endotracheal tube (ETT) balloon; Time 2 (T2) = first ventilation. Data were reported as medians with Interquartile Ranges (IQR, 25%-75%) or percentages with 95% Confidence Intervals (95%, CI). Group comparisons were analyzed by Fisher's Exact Test or Kruskal-Wallis, as appropriate (alpha = 0.017 [three groups], two-tails). Sample size analysis was based upon the power of 80% to detect a difference of 10 seconds between groups at a P = .017; 27 subjects per group would be needed.

RESULTS

All 27 participants completed the study. At T1, there was no statistically significant difference (P = .27) among UP 18.0s (11.5s-19.0s), PC 21.0s (14.0s-23.5s), or CC 17.0s (13.5s-27.5s). For T2, there was also no significant (P = .25) differences among UP 24.0s (17.5s-27.0s), PC 26.0s (21.0s-32.0s), or CC 24.0s (19.5s-33.5s).

CONCLUSION

There were no statistically significant differences in time to balloon inflation or ventilation. Higher levels of PPE do not appear to increase time to ETI.

Manejo de vía aérea en pacientes COVID-19: una encuesta sobre la experiencia de 1125 médicos en España

Antecedentes

Analizamos la experiencia de médicos de la Sociedad Española de Anestesiología en el manejo de vía aérea de pacientes COVID-19.

Métodos

Se realizó una encuesta que incluía 32 ítems (18 abril-17 mayo de 2020). Participaron de forma anónima tras aceptar el consentimiento informado médicos involucrados en intubaciones traqueales en pacientes COVID-19 confirmados o con sospecha. El resultado principal fue el dispositivo de vía aérea preferido para la intubación traqueal. Los resultados secundarios incluyeron el análisis de la práctica clínica, el videolaringoscopio preferido, manejo de vía aérea difícil y uso de equipo de protección personal.

Resultados

Completaron el cuestionario 1125 médicos (tasa de respuesta del 40,9%) que eran mayoritariamente anestesiólogos y trabajaban en hospitales públicos.

El dispositivo preferido para intubar fue el videolaringoscopio (5,1/6) con el siguiente orden de preferencia: Glidescope, C-MAC, Airtraq, McGrath y King Vision. El dispositivo de intubación más utilizado fue el videolaringoscopio (70,5%) con el siguiente orden decreciente: Airtraq, C-MAC, Glidescope, McGrath y King Vision.

La relación de incomodidad de la intubación con equipo de protección personal y la frecuencia de incumplimiento de un paso de seguridad fue estadísticamente significativa, aumentando el riesgo de infección cruzada. La opinión de los médicos senior difería de los más jóvenes en el videolaringoscopio utilizado, número de expertos involucrados en la intubación traqueal y la razón que provocó más estrés durante el manejo de la vía aérea.

Conclusiones

La mayoría de los médicos prefirieron usar un videolaringoscopio con monitor remoto y hoja Macintosh desechable, usando la guía Frova.

Comparison of aerosol box intubation with C-MAC video laryngoscope and direct laryngoscopy-A randomised controlled trial

Background and Aims:

Severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) is a highly infectious disease and healthcare workers are at constant risk for contracting it. Nowadays, aerosol box is used in conjunction with WHO-recommended safety kits, to avoid health workers from getting SARS-CoV-2 infection during aerosol-generating procedures. In our study, we compared the ease of oral intubation with C-MAC video laryngoscope and direct laryngoscopy, when the aerosol box was used. The secondary objectives were to compare the incidence of airway loss, haemodynamic changes, number of attempts, and time required for intubation between these two techniques.

Methods:

This prospective randomised controlled study was conducted on 60 non-coronavirus disease (COVID) patients presenting for elective surgery under general anaesthesia. Patients were randomly assigned into two groups:C and D using a computer-generated random sequence of numbers by closed envelope technique. In group D, laryngoscopy was performed with Macintosh blade and in group C, with Storz® C-MAC video laryngoscope.

Results:

The ease of intubation was better (grade 1) in group C than D (68.6% vs. 31.4% respectively) with a P value of < 0.001. 10% of patients required more than one intubation attempt in group D compared to none in group C, but this difference was not statistically significant. The intubation time was comparable between the two groups. There were no incidences of loss of airway or failure to intubate in both groups.

Conclusion:

The use of C-MAC video-laryngoscopy resulted in easier orotracheal intubation as compared to intubation with direct laryngoscopy when the aerosol box was used.

Comparison of two different shapes of stylets for intubation with the McGrath MAC® video laryngoscope: a randomized controlled trial

Objective

This study was performed to compare two different shapes of stylets, 60° and J-shaped stylets, for intubation using the McGrath MAC® video laryngoscope (MVL).

Methods

Two hundred twenty-two patients undergoing surgery under general anesthesia were randomly allocated to Group J (n = 111) or Group 60° (n = 111) and intubated using the MVL with the stylet bent into the allocated shape. The time to intubation (TTI) and other intubating profiles were compared between the groups. Multivariate regression analysis was used to determine the relationship between factors related to difficult intubation and TTI.

Results

The TTI was not different between the two groups. There were also no differences in the intubating profiles between the two groups. In both groups, the TTI was longer with a modified Mallampati score (mMS) of ≥3 and percentage of glottic opening (POGO) score of <50. In Group J, the TTI was longer with a body mass index (BMI) of ≥30 kg/m².

Conclusion

The TTI during tracheal intubation with the MVL was not different between the two groups. The TTI was longer with an mMS of ≥3 and POGO score of <50. In Group J, the TTI was longer with a BMI of ≥30 kg/m².

Effect of C-MAC Video Laryngoscope-aided intubations Using D-Blade on Incidence and Severity of Postoperative Sore Throat

Background:

Video laryngoscope-aided intubations require less force to align oral, pharyngeal, and laryngeal planes to visualize the glottis opening during intubation.

Aim:

The primary objective of the study was to assess the incidence and severity of postoperative sore throat (POST) in patients who were intubated with C-MAC video laryngoscope using D-blade versus traditional Macintosh laryngoscope.

Settings and Design:

This prospective, randomized, open label study was conducted in a tertiary care institution.

Subjects and Methods:

A total of 130 patients undergoing short elective laparoscopic surgeries lasting <2 h were recruited. All patients received general anesthesia as per a standardized protocol. Laryngoscopy was performed using traditional Macintosh laryngoscope in Group M and with Storz^® C-MAC video laryngoscope using D-Blade in Group V. The endotracheal tube cuff pressure was maintained at 20–22 cm of H2O intraoperatively.

Statistical Analysis Used:

Pearson's Chi-square test, Fisher's exact test, and Independent sample t-test were used in this study.

Results:

As compared to Group M, number of patients who had POST, hoarseness of voice, and cough was significantly low in Group V at 2, 6, 12, and 24 h. Severity, as well as the incidence of all these symptoms, showed a downward trend in both groups with time. Significantly more number of patients in Group M required rescue therapy for POST (44.6% as compared to 7.7%, P < 0.001).

Conclusion:

C-MAC video laryngoscope-aided intubations using D-blade significantly reduced the incidence and severity of POST, hoarseness of voice, and cough following orotracheal intubation as compared to use of traditional Macintosh laryngoscope.

Ease of Intubation with C-MAC Videolaryngoscope: Use of 60° Angled Styletted Endotracheal Tube versus Intubation over Bougie

Background:

Although videolaryngoscopes improve glottic visualization, their actual usefulness in intubation is not yet established.

Aims:

The primary objective was to compare the ease of oral intubation with the use of 60° angled styletted endotracheal tube versus that performed over bougie inserted under videolaryngoscopic guidance. The secondary objectives were assessment of incidence of airway loss, hemodynamic changes, and time and number of attempts at intubation.

Settings and Design:

This prospective randomized study was conducted in a tertiary care institution.

Patients and Methods:

Seventy surgical patients requiring oral intubation were randomly allotted to Group S or Group B. Laryngoscopy was performed with Storz^® C-MAC videolaryngoscope using D-Blade. In Group S, patients were intubated with a 60° angled stylletted endotracheal tube. In Group B, a bougie was introduced into the trachea and endotracheal tube was railroaded over the bougie.

Statistical Analysis Used:

Chi-square test and independent sample t-test were used as applicable.

Results:

The ease of intubation was significantly more in patients of Group S as compared to Group B (88.6% vs. 25.7%, respectively, P < 0.001) with significantly shorter intubation time (16.97 ± 7.91 vs. 77.43 ± 35.55 s, respectively, P < 0.001). The requirement of more than one attempt at intubation was significantly higher in Group B [57.1% vs. 5.7% P < 0.001, respectively]. Group B showed a significantly high mean arterial pressure at 1 and 3 min following intubation with no significant change in heart rate.

Conclusion:

Use of 60° angled styletted endotracheal tube resulted in easier and faster intubation as compared to intubation over a bougie when used with C-MAC videolaryngoscope.

Comparison of the Pentax AirwayScope and McGrath MAC videolaryngoscope for endotracheal intubation in patients with a normal airway

Various videolaryngoscopes (VLs) have been developed to provide a better laryngeal view and facilitate difficult intubations. The goal of this study was to compare 2 VLs, the Pentax AWS and the McGrath VL, with respect to intubation time and ease of intubation.One hundred forty patients aged 19 to 65 years (American Society of Anesthesiologists classification I or II), who required tracheal intubation for elective surgery, were randomly assigned to 1 of the 2 groups: the Pentax AWS (n = 70) or the McGrath VL (n = 70). The primary outcome was time to intubation (TTI) measured by a blind observer. The intubation difficulty scale (IDS), percentage of glottic opening (POGO) scale, glottic grade, use of optimal external laryngeal manipulation (OELM), and ease of intubation were also recorded.The Pentax AWS provided a better laryngeal view than the McGrath VL with respect to the Cormack-Lehane (CL) glottic grade (1/2a/2b) (63/7/0 vs 43/24/3, P < .001) and the POGO scale (median [interquartile range, IQR]) (100 [100-100] vs 100 [80-100], P < .001). The IDS was significantly lower in the Pentax AWS group compared with the McGrath VL group (median [IQR]) (0 [0-0] vs 0 [0-1], P < .001). However, the TTI was similar in both the Pentax AWS and McGrath VL groups (median [IQR]) (30 [27-34] vs 32 [27-35] seconds, P = .440). OELM and ease of intubation were also similar between the 2 groups.The Pentax AWS offered a superior laryngeal view compared with the McGrath VL. There was no significant difference in either the intubation time or ease of intubation using these 2 devices in patients with normal airways.